Provider Demographics
NPI:1235444183
Name:COCOA BEACH DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:COCOA BEACH DISCOUNT PHARMACY LLC
Other - Org Name:COCOA BEACH DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HETALBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-799-2030
Mailing Address - Street 1:291 W COCOA BEACH CSWY
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3529
Mailing Address - Country:US
Mailing Address - Phone:321-799-2030
Mailing Address - Fax:321-799-2050
Practice Address - Street 1:291 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3529
Practice Address - Country:US
Practice Address - Phone:321-799-2030
Practice Address - Fax:321-799-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH248123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002760200Medicaid
5701354OtherNCPDP PROVIDER IDENTIFICATION NUMBER